Access to Antiretroviral Drugs in Brazil

From CDC National Prevention Information Network

January 30, 2003

Since 1996, the Brazilian Ministry of Health has offered
free, universal access to antiretroviral treatment for people
living with HIV/AIDS. This well-known aspect of the Brazilian
National AIDS Program has had political, financial and logistical
challenges. The current study examines the history and context of
Brazil's antiretroviral policy, the logistics of the drugs'
distribution and the government's strategies for acquiring the
drugs.

In 1988, the Brazilian public health system began to
distribute drugs to treat opportunistic infections; in 1991, it
started to offer zidovudine. In November 1996, Brazilian
president Fernando Henrique Cardoso signed a law establishing
free distribution of antiretrovirals to HIV/AIDS patients. Since
the coordinated distribution began, the number of people
receiving treatment has steadily increased.

Brazil's government continues the distribution program
despite escalating drug costs for two reasons: the reduction of
deaths and the reduction in hospital admissions and associated
treatment costs from opportunistic infections. Other benefits of
the program are a reduction in under-reporting of cases, enhanced
quality of life for HIV/AIDS patients, increased numbers of
people getting tested, and the social recognition patients gained
when the government affirmed their value to society by upholding
their right to treatment.

Logistically, the country was challenged to devise a
strategy to distribute and monitor antiretrovirals through the
public health system. Currently, Brazil has 424 sites where
patients can receive antiretrovirals, called AIDS Drugs
Dispensing Units, and located in public hospitals or health
centers. The National AIDS Program implemented a system in 1998
to keep computerized records of drug distribution and to track
prescriptions. Another database tracks test results and generates
graphs of changes in CD4 and viral load for clinicians' use. To
ensure confidentiality, access to both databases is limited, and
patients' names are not divulged.

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The high cost of antiretrovirals is one hazard to Brazil's
continuation of free and widespread access to the drugs. To
assuage that difficulty, Brazil has steadily increased its
domestic share of drug production, until by the end of 2001, the
country was producing seven of the 13 antiretrovirals used to
treat its citizens. On the international market, Brazil has
sought to negotiate the best possible price for pharmaceuticals,
sometimes threatening to break patents if pharmaceutical
companies do not reduce their prices. Called compulsory
licensing, the practice is permissible under certain
circumstances according to Brazilian patent law. Although it has
not invoked compulsory licensing, Brazil has used the threat to
pressure manufacturers into lowering prices on drugs such as
nelfinavir and efavirenz. In November 2001, the World Trade
Organization released a declaration allowing the use of
compulsory licensing in cases of national public health
emergencies, a development that strengthened Brazil's position
and possibly paved the way for other developing nations to
acquire HIV/AIDS drugs at lower costs.

"In conclusion," the author wrote, "the Brazilian response
to the HIV/AIDS epidemic merits being seen as an example of one
developing nation's determination to meet the treatment needs of
people living with HIV/AIDS. Although local realities could make
it difficult to apply the Brazilian model to other countries,
much can be learned from Brazil's experience. At the same time,
the country's commitment to free and widespread access to
antiretroviral treatment warrants further study with respect to
its effectiveness, dynamics, and sustainability."

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